Project Request Form
Wayne State University / Crittenton Hospital Medical Center
This form must be completed and processed BEFORE any work on the project begins.
Project Title ____________________________________________________________
Type of project (circle one): Quality Improvement
Research
Quality Improvement Project
Problem Statement/Aim:(what is the problem you
Research Project
Hypothesis:
What PDSA tools do you plan to use for this project?
Describe efforts to research and learn previous studies on
this topic
currently see? – DO NOT include any solutions)
Which hospital initiative(s) does this project align with?
Date of Request ______________________
Data Needed by_____________________
Requestor __________________________
Department _________________________
Phone ____________________________
Email _____________________________
Quality Improvement Project
Research Project
Description of data needed:
Background supporting method of testing hypothesis and
describe what data you want to collect and analyze
Type of data (circle one):
What procedures will you use to collect data?
Root cause analysis Process measure
Outcome measure
Date Range of Data to be included _____________to_____________
Codes to Include (circle one or more and specify below):
DRG
ICD-9
CPT-4
**Contact Medical Records to determine specific codes needed**
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rev. Oct 2014
Other Data Fields to be Included (circle one or more):
FIN
Patient Name
Dates of Service
LOS
Patient Age
Attending
Other:
Data will be provided in Excel format
The project has been presented to the Task Force for Quality Improvement and agreed to be a
(circle one) Quality Improvement Project / Research Project.
Date Reviewed: ___________________
QI Project Sign Off:
The data being collected for this project is being used as part of a process improvement initiative and
not a research project. I understand the data may contain patient identifiers and have reviewed the
CHMC HIPPA Administrative Requirements policy. Any identifiers given will be used to find the root
cause of the problem, measure the process, and/or the outcome of the process change. It is my
responsibility to delete/remove patient identifiers from the data set. I certify I will delete identifiers
14-01_administrative
from the data set after collecting information.
_guidance_policy_(hipaa)_-_
Requestor Signature: ________________________________ Date: _________________
Program Director:__________________________________
Name Printed
Signature: ________________________________________ Date: _________________
Quality and Outcomes Department Sign-Off
_______________________________________________ Date: __________________
Lisa Takis – Quality and Outcomes Manager
Research Project Data Recipient Sign Off:
I understand that I have been provided with patient identifiers for the sole purpose of retrieving
information. It is my responsibility to delete/remove patient identifiers from the data set. I certify I
will delete identifiers from the data set after collecting information.
Requestor Signature: _____________________________________
Date: _________________
Program Director:________________________________________
Name Printed
Signature: ______________________________________________
Date: _________________
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rev. Oct 2014